Laserfiche WebLink
SAN JOAQUIN: LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave.,:,Stockton, CA 95206 Permit No. <br /> : F Telephone: (209) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date IssueM-2- <br /> This Permit Ex ices I Year From Date 'Issued <br /> Complete In Triplicate ; <br /> Application is hereby made to;the San Joaquin Local, Health District for a permit to construct <br /> and/or install the work herein described. This application: i-s made .in _comp.liance .with San <br /> �Oaquin : r. ` <br /> County`rOrdinance yo: 1862 and- the Rules - and Regulations of the, San. Joaq�in Local Health <br /> District. <br /> EXACT STREET ADDRESS. Z9 0 . CITY/TOWN <br /> Owner's Name 4L Phone <br /> Address, 1P Ica 66 City '"- <br /> Contractor's Name �. <br /> �---5 License#- 3fK755 Phone <br /> IS CERTIFICATE OF .WORKf1AtJ'S•�CO, -MSATI04J=-iNSURAILICE--Ol-�-FI-LE-WITH-SJLHD?-- YES <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE�DISPOSAL FIELD CESSPOOL/SEEPAGE PIT - OTHER W <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS W <br /> Industrial Cable.,.Tool Dia. of Well Excavation <br /> Domestic/privateL Drilled. Dia. of Well Casing <br /> Domestic/public Driven:-yGauge of Casing <br /> Irrigation � Gravel Pack - Depth of Grout Seal <br /> Cathodic Protection i Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b <br />'UMP INSTALLATION: Contractor V <br /> Type of ;Pump H.P40 <br /> LUMP REPLACEMENT: []State Work Done <br />'UMP -REPAIR-:_ --❑S`tate Work Done <br />)ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby certify that I have prepared this application and that the work will be done in accordancE <br /> pith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local ' <br /> ealth District. Home owner or licensed agent's signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shat ] <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California." <br /> WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> IGNED i s/ r '.' TITLE <br /> DATE: Y <br /> y DR W PLOT: PL N ON REVERSE S E <br /> LASE I FOR DEPARTMENT USE ONLY <br />'PLICATION ACCEPTED BY .,° _..... DATE � ��� <br />)DITIONAL COMMENTS : i: :,Y; ;,. ----- <br /> PHASE II GROUT INSPECTIONPHASE III F NAL INSPECTION <br />)SPECTION BY DATE �� .�� : . <br /> INSPECTION BY DATE /' <br /> I�1.426 Re 19- 7 <br />